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Do Kinematics Matter

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Do Kinematics Matter To improve walking function in ambulatory patients with stroke, incomplete spinal cord injury, and brain injury… Should therapists focus on normalizing kinematics? What does the data say? The locomotor CPG1 recommends focusing on three active ingredients for our interventions. Recommended interventions are specific to gait, challenge aerobic intensity, in high repetitions. Specificity Intensity Repetition How does this recommendation compare to other approaches? Paradigm Theory Method Evidence Active Ingredients? Impairment- Address Standing balance and weight • Poor and inconsistent carryover of impairment-based Specificity.…… based treatment underlying shifting exercises, lower treatment into walking function.1-4 impairments extremity strength & transfer • Less effective than High Intensity Gait Training (HIGT) for Intensity.......... leading to gait training. walking speed, distance, and quality.3-6 abnormalities • No more effective than HIGT for transfers & balance.3-5 Repetition....... Bobath / Neuro Sensory input is Movement analysis followed by • Less effective than other interventions for improving gait Developmental fundamental to part & whole task training that speed, gait quality, and length of stay.2 Specificity.….... Treatment (NDT) motor control and minimizes compensatory • Even with experienced and highly NDT-trained clinicians, normal movement movements. Sensory input gait quality or speed may not improve.8 Intensity………. patterns define provided to facilitate desired 7 7 success movement quality. Repetition……. 0 Body Weight Use of sensory Partial weight support provided • Neither BWSTT nor RAS is superior to traditional low 0 Supported input to stimulate while focusing on optimal intensity overground gait training or treadmill training with Specificity….. Treadmill central pattern kinematics, weight bearing, and a single therapist.1,9 Training (BWSTT) generators and sensory input with 2-3 • Both require additional personnel and equipment Intensity.….... 0 and activity-induced therapists (BWSTT) or a robot resources. 0 Robotic Assisted neuroplasticity 9 (RAS). • Excessive therapist or robotic assist limits intensity.8 Repetition…... Stepping (RAS) • Practicing normal movement patterns does not result in more normalized spatiotemporal patterns.10 High Intensity High aerobic Stepping practice at high • Consistent improvements in walking speed & distance Gait Training intensity and aerobic intensities (70-85% compared to conventional PT.1,3-5 Specificity….. (HIGT) repetitive HRmax), without specific focus • Better outcomes than lower intensity walking practice.11 stepping in on training normal movement, • Better outcomes than high intensity impairment-based tx.3 Intensity…….. variable contexts on a treadmill, overground, and • Increases muscle activity but does not worsen spastic may drive stairs.12 Successful defined by muscle behaviors.13 Repetition…… neuroplasticity achieving essential • Improved walking function via recovery of more normalized and adaptations in Biomechanical Subcomponents kinematics, improved motor neuro pool selection, more cardiopulmonary (see reverse). consistent intralimb coordination, and increased non- fitness during gait paretic limb force generation and excursion.6,14-15 training www.neuropt.org [email protected] Evidence Summary ➢ Focusing on normalizing kinematics is not a critical training parameter and reduces the amount and intensity of task-specific walking practice. ➢ High Intensity Gait Training, despite not focusing on normal kinematics, improves gait quality better than conventional approaches while also achieving superior improvements in walking speed & distance. ➢ Intensity Matters! References: 1. Hornby TG, et al. Clinical Practice Guideline to Improve Locomotor Function Following Chronic Stroke, Incomplete Spinal Cord Injury, and Brain Injury. Journal of Neurologic Physical Therapy. 2020; 44: 49-100. 2. Veerbeek JM, et al. What is the Evidence for Physical Therapy Poststroke? A Systematic Review and Meta-analysis. PLoS One. 2014; 9(2): E87987. 3. Lotter JK, et al. Task-Specific Versus Impairment-based Training on Locomotor Performance in Individuals with Chronic Spinal Cord Injury: A Randomized Crossover Study. Neurorehabilitation and Neural Repair. 2020; 34(7): 627-639. 4. Hornby TG, et al. Variable Intensive Early Walking Poststroke (VIEWS): A Randomized Controlled Trial. Neurorehabilitation and Neural Repair. 2016; 30(5): 440-450. 5. Moore JL, et al. Implementation of High-Intensity Stepping Training During Inpatient Stroke Rehabilitation Improves Functional Outcomes. Stroke. 2020: 51: 563-570. 6. Mahtani GB, et al. Altered Sagittal- and Frontal-Plane Kinematics Following High Intensity Stepping Training Versus Conventional Interventions in Subacute Stroke. Physical Therapy Journal. 2017; 97(3): 320-329. 7. Vaughan-Graham J, et al. The Bobath (NDT) concept in adult neurological rehabilitation: what is the state of the knowledge? A scoping review. Part I: conceptual perspectives. Disability and Rehabilitation. 2015; 37(20): 1793-1807. 8. Lennon S, et al. Gait outcome in outpatient physiotherapy based on the Bobath concept in people post stroke. Disability and Rehabilitation. 2006; 28(13-14): 873-881. 9. Dobkin B, et al. Should Body Weight-Supported Treadmill Training and Robotic-Assistive Steppers for Locomotor Training Trot Back to the Starting Gate? Neurorehabil Neural Repair. 2012; 26(4): 308-317. 10. Hornby TG, et al. Enhanced Gait-Related Improvements After Therapist- Versus Robotic-Assisted Locomotor Training in Subjects with Chronic Stroke: A Randomized Controlled Study. Stroke. 2008; 39(6): 1786-1792. 11. Hornby TG, et al. Contributions of Stepping Intensity and Variability to Mobility in Individuals Poststroke: A Randomized Clinical Trial. Stroke. 2019; 50(9): 2492-2499. 12. Holleran CL, et al. Feasibility and Potential Efficacy of High-Intensity Stepping Training in Variable Contexts in Subacute and Chronic Stroke. Neurorehabilitation and Neural Repair. 2014; 28(7): 643-651. 13. Leech KA, et al. Effects of Locomotor Exercise Intensity on Gait Performance in Individuals With Incomplete Spinal Cord Injury. Physical Therapy Journal. 2016; 96(12): 1919-1929. 14. Ardestani MM, et al. Compensation or Recovery? Altered Kinetics and Neuromuscular Synergies Following High-Intensity Stepping Training Poststroke. Neurorehabilitation and Neural Repair. 2019; 33(1): 47-58. 15. Ardestani MM, et al. Kinematic and Neuromuscular Adaptations in Incomplete Spinal Cord Injury after High- versus Low-Intensity Locomotor Training. Journal of Neurotrauma. 2019; 36: 2036-2044. www.neuropt.org [email protected].
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